OxyContin and Heroin: A Cause-Effect Relationship
In a recent Testimony to Congress on May 1, 2014, the National Institute on Drug Abuse (NIDA) reported the most recent statistics relating to the use of and addiction to OxyContin and heroin. Some of you reading this may wonder, why is an increasingly popular, medically approved, prescription pain medication being discussed side-by-side with one of the most dangerous and addictive illicit street drugs? The relationship between OxyContin and heroin can be seen through a few of the facts provided in NIDA’s testimony:
- 4-36 million people worldwide abuse opioids, which include OxyContin and heroin.
- Approximately 1 million Americans are addicted to prescription opioid pain medications
- According to the US Dept. of Health and Human Services, OxyContin is the most widely abused opioid medication
- Approximately 467,000 Americans are addicted to heroin
Factors leading from OxyContin abuse to heroin use
- Drastic increases in the number of opioid medications written and dispensed
- The abuse-deterrent reformulation of OxyContin in 2013 made misusing the medication more difficult; this, along with difficulties obtaining the medication for non-medical purposes has led to high street prices
- Evidence shows that OxyContin abuse leads to an increase in heroin use when prescriptions become more expensive and difficult to obtain
Endorphins, Encephalins, and Opioids
A basic understanding of the body’s natural pain management system is helpful in understanding the current epidemic of OxyContin abuse and heroin addiction. In a healthy individual, the endocrine system produces natural analgesics, called endorphins (endo = produced by the body orphin = morphine-like). The most powerful endorphins are known as beta (β-endorphin) which is released by the hypothalamus and pituitary gland during stress and pain. This is the same endorphin responsible for the “runner’s high”, a period of extra energy, decreased pain, and elevated mood experienced after a rigorous bout of exercise. Encephalins are natural opiate-like hormones released by the brain and spinal cord. The two encephalins involved in pain management are the met-encephalin and the leu-encephalin. They work by blocking pain messages in the brain stem.
Opioids are synthetic compounds that mimic the actions of endorphins and encephalins. Opioid compounds are all organically related to the opium poppy. Codeine and morphine are two opioid compounds that serve as a “base” for the many prescription pain medications used in healthcare around the world. OxyContin is an opioid prescription pain medication structurally related to codeine. Heroin is an opioid street drug structurally related to morphine. When it reaches the brain, regardless of administration, heroin converts to morphine.
Brief Histories of OxyContin and Heroin
Oxycodone was first developed in Germany in 1916 as a stronger, longer acting alternative to morphine. It was introduced to the US in 1939 for post-operative pain management; it was only approved for clinical use. In 1995, OxyContin, the brand name of oxycodone tablets, was released on the market by Purdue Pharma as a Schedule II narcotic prescription pain medication. Schedule II medications are recognized as medically significant, but with recognized high potential for abuse and severe physical and psychological dependency. It is illegal to be in possession of or use a Schedule II drug without a prescription.
Heroin was developed in Germany in the early 20th century and widely used to treat the chronic cough and pain experienced by tuberculosis and pneumonia patients. It was initially believed to be safer and more effective than morphine. Shortly after its introduction to the US in 1905, its addiction potential was realized. In 1910, New York’s Bellevue Hospital admitted its first patient for treatment of heroin addiction. Since 1924, heroin has been recognized as a “vice of the underworld”. As a Schedule I drug, it has no acceptable medical use; it is harmful, with severe physical and psychological dependency and addiction potentials.
Cause-and-Effect Relationship of OxyContin and Heroin
Cause: Shortly after its introduction in 1995, OxyContin’s abuse potential was fully recognized. Abusers not only took dangerous amounts of the medication or mixed them with alcohol and other medications to increase the effects; they also crushed the pills and snorted them or mixed the pulverized tablet for intravenous use. Users also removed the outer layer of the extended-release tablets to create an instant release pill that would intensify the effects of the medication; it also increased the danger of the medication. Due to the increasing rate of abuse, the makers of OxyContin released an abuse-deterrent reformulation in 2013. Designed to be more difficult to crush or break, it also forms a viscous hydrogel when mixed with water or moisture, such as would be found in a mucous membrane like the nasal passages.
To reduce accessibility, the DEA announced that it would not approve of any generic formula of OxyContin; this restriction has ensured that the street price of OxyContin remains high. Without a prescription and without medical insurance to offset the cost, the street cost is approximately $1 per milligram; tablet doses start at 10mg and extend as high as 160mg, in the extended-release formula. Additionally, access to a consistent supply of OxyContin, as a controlled substance, is difficult; this further increases the street price.
Effect: Eventually, users of OxyContin are forced into a dangerous position. Physically and psychologically dependent, users face two inevitabilities: scarce supplies and dwindling finances. Many of those addicted to OxyContin make the switch to heroin, which is easily available off the street and significantly less expensive. In large American cities, like Chicago, the average cost of heroin can be as cheap as $5 per bag. In addition, individuals who have developed a tolerance to the effects of OxyContin are left with little alternatives to achieve a “high”, other than heroin. The cause-and-effect relationship of OxyContin and heroin has been reported by several agencies across the US, where a decrease in OxyContin availability led to an anticipated increase in heroin related hospital admissions, crimes, and fatal overdoses.
Similarities and Differences
Although OxyContin is a medically relevant medication, the euphoric effects are very similar to those of heroin; in some areas of the country, it has earned the nickname, “hillbilly heroin”. Like most powerful opiates, heroin and OxyContin produce the same intoxication effects: pinpoint pupils, drowsiness, euphoria, decreased respiration and heart rate, and increased sense of well-being. Similarly, both drugs also have negative side effects, including constipation, dry mouth, and tolerance. They also share the same pattern of substance abuse and addiction: drug seeking, intoxication, and withdrawal. Withdrawal symptoms include diarrhea, anxiety, vomiting/nausea, insomnia, and possible seizures.
The biggest difference between the two drugs is social perception. Culturally, Americans perceive prescription pain medication as safe and socially acceptable, perhaps due to the aggressive marketing by pharmaceutical companies. Heroin is more dangerous than OxyContin in that its properties are uncontrolled; dealers often use vitamins, pain medications, and other unidentified substances to “cut” heroin, thereby making the final product variable in many ways. Currently, the Unites States is facing a terrifying epidemic of heroin cut with another powerful opiate: fentanyl. Fentanyl intensifies the effects of heroin and significantly increases its lethality; to the average user, there is little way of knowing whether fentanyl is present in their heroin or not. Unfortunately, for many, toxicology results post-mortem provides that information. The health and financial consequences of OxyContin addiction are equally as devastating as those related to heroin addiction. Together, OxyContin and heroin contribute to the estimated $72.5 billion price tag of healthcare costs related to substance abuse and addiction.
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